Inter- and intraobserver agreement of three classification systems for lateral clavicle fractures - reliability comparison between two specialist groups

Characteristics of Lateral Clavicle Fractures Treated With Coracoclavicular Ligament Repair or Reconstruction in a Military Population

INTRODUCTION

Lateral clavicle fractures comprise a minority of all clavicle fractures and are associated with high rates of nonunion when managed nonoperatively. Various fixation methods have been described, including augmentation with coracoclavicular (CC) ligament repair or reconstruction. Outcomes following the surgical treatment of lateral clavicle fractures are limited to small case series and systematic reviews, and the literature within physically demanding populations remains sparse. We sought to describe the characteristics and complications of operative lateral clavicle fractures treated with CC ligament repair or reconstruction within the Military Health System.

MATERIALS AND METHODS

We queried the U.S. Military Health System Data Repository for patients with a lateral clavicle fracture treated with CC ligament repair or reconstruction between October 2013 and March 2020. We reviewed electronic health records, including patient demographics, radiographs, operative reports, and clinical notes, to assess injury characteristics, surgical constructs, postoperative complications, and functional outcomes.

RESULTS

A total of 40 patients underwent CC ligament repair (n = 20, 50%) or reconstruction (n = 20, 50%) for treatment of lateral clavicle fractures during the study period. Twenty-two (55%) patients underwent surgery within 6 weeks of injury, and 40% (n = 18) required concomitant open reduction and internal fixation. Complications included adhesive capsulitis (n = 3, 7.5%), unplanned return to the operating room (n = 4, 10%), and loss of CC reduction (n = 10, 25%). Twenty-six (65%) patients achieved a full, pain-free range of motion. There was a statistically significant association between postoperative complications and shoulder pain or diminished range of motion (P = .026). Seven of 32 (21.9%) active-duty service members required medical separation from military service. Female sex (P = .04) and distal clavicle plate fixation increase the risk of unplanned return to the operating room (P = .01). Nicotine use was predictive of eventual military separation (P = .004).

CONCLUSIONS

In this case, a series of lateral clavicle fractures treated with CC ligament repair or reconstruction, all patients achieved fracture union and the majority of patients regained full, pain-free range of motion. Complications were common and portended a poor functional outcome. At the conclusion of their fracture care, 1 in 5 active-duty patients necessitated medical separation from military service.

A Korean field trial of ICD-11 classification under practical clinical coding rules to clarify the reasons for inconsistencies

Background: The World Health Organization (WHO) announced the release of the 11th edition of the International Classification of Diseases (ICD) in May 2019. Although Statistics Korea has been involved in the ongoing research on ICD-11 since 2017, we have been unable to achieve agreement on the gold standards for case scenario clinical coding in previous studies due to high levels of variance in the coding results of participants. Objective: The purpose of this study was to enhance clinical coding accuracy and consistency in ICD-11 by identifying and clarifying the reasons for these inconsistencies through the use of clear clinical coding rules. Method: A pre-experimental design was applied. Two clinical coding field trials (FTs) were conducted in 'ICD-11 for Mortality and Morbidity Statistics (2022 Mar)' targeting diagnostic terms and case scenarios. In the first FT, clinical coding rules were derived by analysing the results, while the second FT was performed under the clinical coding rules set by the first FT. Results: Across the two FTs, accuracy rates for diagnostic terms (75.8% and 71.8%, respectively) were higher than for case scenarios (62.5% and 71.9%). The main reason for the low accuracy levels was post-coordination. Conclusion: For case scenario clinical coding, low accuracy could be explained by variance in clustering methods between participants. This suggests that the accuracy of ICD-11 clinical coding could be increased if the variance between clustering methods can be reduced through the use of a clear coding guide. A guide for various ambiguous cases in each institution and the provision of a proper post-coordination list in the stem code could also be effective.

A new classification system for distal clavicle fractures: based on fracture location and ligament integrity

INTRODUCTION

Although various classification systems have been introduced for the description of distal clavicle fractures, there is no consensus on the best classification system that is helpful in determining treatment and prognosis. The objective of this study was to establish a new classification system for distal clavicle fractures and to verify the reliability of the new classification system by evaluating the inter- and intraobserver agreement.

MATERIALS AND METHODS

A total of 1075 consecutive patients with distal clavicle fractures were selected from five university-affiliated hospitals between 2012 and 2022. The distal fragment size (DFS), the coracoclavicular distance (CCD) and the acromioclavicular distance (ACD) were measured on anteroposterior radiographs of each acromioclavicular joint. Twenty independent investigators evaluated 1075 radiographs of distal clavicle fractures, completing the fracture typing according to the new classification system and selecting a treatment choice for each case. This procedure was repeated 3 months later. Fleiss κ values were calculated to estimate the inter- and intraobserver agreement.

RESULTS

The new classification categorizes distal clavicle fractures into three types based on the relationship between fracture location and ligament footprints. Type I fractures occur distal to the coracoclavicular (CC) ligaments with or without ligament injury. Type II fractures occur CC ligament attachment regions with ligament injury Type III fractures occur proximal to the CC ligaments without ligament injury. Several subtypes (types IA, IB, IC, ID, IIA, IIB, IIC, IID, and IIE) were further introduced according to fracture displacement and ligament integrity. The inter- and intraobserver reliability of our new classification system was substantial (κ = 0.622 vs. 0.678). Inter- and intraobserver reliability for treatment choice was perfect (κ = 0.846 vs. 0.882).

CONCLUSIONS

The new classification system which takes into account fracture location and ligament integrity brought few disputes in category division and treatment selection.

Reliability of the 2018 Revised Version of AO/OTA Classification for Femoral Shaft Fractures

Background

The Arbeitsgemeinschaft für Osteosynthesefragen (AO) and the Orthopaedic Trauma Association (OTA) classification system for diaphyseal fracture has been recently revised to refine and enhance the accuracy of fracture categorization. This study aimed to investigate the interobserver reliability of the new AO/OTA classification and to compare it with the older version in femoral shaft fractures.

Methods

We retrospectively analyzed 139 patients (mean age, 43.8 ± 19.5 years; 92 men and 47 women) with femoral shaft fractures who were treated from 2003 to 2017. Four well-trained observers independently classified each fracture following the previous and revised AO/OTA classification system. We calculated the Fleiss kappa for the interobserver reliability.

Results

The previous classification showed the kappa value of 0.580 (95% confidence interval [CI], 0.547-0.613), and the revised version showed 0.528 (95% CI, 0.504-0.552). Both the old and the revised versions showed moderate reliability.

Conclusions

Our study highlights the moderate interobserver reliability of both the previous and new AO/OTA classification systems for diaphyseal femur fractures. These findings emphasize the importance of standardized systems in clinical decision-making and underscore the need for ongoing education and collaboration to enhance fracture classification.

Comparison of Interobserver Agreement of Four Classification Systems for Lateral Clavicle Fractures between Two Groups of Surgeons: A Multicenter Study

OBJECTIVE

Distal clavicle fracture classification directly affects the treatment decisions. It is unclear whether the classification systems implemented differ depending on surgeons' backgrounds. This study aimed to compare the interobserver agreement of four classification systems used for lateral clavicle fractures by shoulder specialists and general trauma surgeons.

METHODS

Radiographs of 20 lateral clavicle fractures representing a full spectrum of adult fracture patterns were analyzed by eight experienced shoulder specialists and eight general trauma surgeons from 10 different hospitals. All cases were graded according to the Orthopedic Trauma Association (OTA), Neer, Jäger/Breitner, and Gongji classification systems. To measure observer agreement, Fleiss' kappa coefficient (κ) was applied and assessed.

RESULTS

When only X-ray films were presented, both groups achieved fair agreement. However, when the 3D-CT scan images were provided, improved interobserver agreement was found in the specialist group when the OTA, Jäger/Breitner, and Gongji classification systems were used. In the generalist groups, improved agreement was found when using the Gongji classification system. In terms of interobserver reliability, the OTA, Neer, and Jäger/Breitner classification systems showed better agreement among shoulder specialists, while a slightly lower level of agreement was found using the Gongji classification system. For the OTA classification system, interobserver agreement had a mean kappa value of 0.418, ranging from 0.446 (specialist group) to 0.402 (generalist group). For the Neer classification system, interobserver agreement had a mean kappa value of 0.368, ranging from 0.402 (specialist group) to 0.390 (generalist group). For the Jäger/Breitner classification system, the inter-observer agreement had a mean kappa value of 0.380, ranging from 0.413 (specialist group) to 0.404 (generalist group). For the Gongji classification system, interobserver agreement had a mean kappa value of 0.455, ranging from 0.480 (specialist group) to 0.485 (generalist group).

CONCLUSION

Generally speaking, 3D-CT scans provide a richer experience that can lead to better results in most classification systems of lateral clavicle fractures, highlighting the value of digitization and specialization in diagnosis and treatment. Competitive interobserver agreement was exhibited in the generalist group using the Gongji classification system, suggesting that the Gongji classification is suitable for general trauma surgeons who are not highly experienced in the shoulder field.

The influence of 3D printing on inter- and intrarater reliability on the classification of tibial plateau fractures

PURPOSE

Tibial plateau fractures continue to be a challenging task in clinical practice and current outcomes seem to provide the potential for further improvement. Especially presurgical understanding of the orientation of fracture lines and fracture severity is an essential key to sufficient surgical treatment. The object of this study was to evaluate the reliability of modern axial CT-based classification systems for tibial plateau fractures. In addition, the diagnostic-added value of 3D printing on the classification systems was investigated.

METHODS

22 raters were asked to classify 22 tibial plateau fractures (11 AO B- and 11 AO C-fractures) with the AO, the 10-Segment and the Revisited Schatzker classification in a three-step evaluation: first only using CT scans, second with 3D volumetric reconstructions and last with 3D-printed fracture models. Inter- and intraobserver agreement and the subjective certainty were analyzed. Statistics were done using kappa values, percentage match and a univariant one-way analysis of variance.

RESULTS

The AO classifications interobserver percentage match and kappa values improved for all raters and recorded an overall value of 0.34, respectively, 43% for the 3D print. The 10-Segment classification interobserver agreement also improved with the 3D-printed models and scored an overall kappa value of 0.18 and a percentage match of 79%. Equally the Revisited Schatzker classification increased its values to 0.31 and 35%. The intraobserver agreement showed a moderate agreement for the AO (0.44) and Revisited Schatzker classification (0.42) whereas the 10-Segment classification showed a fair agreement (0.27). Additionally, the raters changed their classification in 36% of the cases after evaluating the fracture with the 3D-printed models and the subjective certainty regarding the decisions improved as categories of self-reliant diagnostic choices were selected 18% (p < 0.05) more often after using the 3D-printed models.

CONCLUSION

Based on the measured outcomes it was concluded that the new classification systems show an overall slight to fair reliability and the use of 3D printing proved to be beneficial for the preoperative diagnostics of tibial plateau fractures. The 10-Segment classification system showed the highest percentage match evaluation of all classification systems demonstrating its high clinical value across all levels of user experience.

Monopolar and Bipolar Combination Injuries of the Clavicle: Retrospective Incidence Analysis and Proposal of a New Classification System

Clavicle injuries are common, but only few case reports describe combined clavicular injuries (CCI). CCI include combinations between clavicular fractures and acromioclavicular/sternoclavicular joint dislocations (SCJD). We present the first general therapeutic recommendations for CCI based on a new classification and their distribution. A retrospective, epidemiological, big data analysis was based on ICD-10 diagnoses from 2012 to 2014 provided by the German Federal Statistical Office. CCI represent 0.7% of all clavicle-related injuries (n = 814 out of 114,003). SCJD show by far the highest proportion of combination injuries (13.2% of all SCJD were part of CCI) while the proportion of CCI in relation to the other injury entities was significantly less (p < 0.023). CCIs were classified depending on (1) the polarity (monopolar type I, 92.2% versus bipolar type II, 7.8%). Monopolar type I was further differentiated depending on (2) the positional relationship between the combined injuries: Ia two injuries directly at the respective pole versus Ib with an injury at one end plus an additional midshaft clavicle fracture. Type II was further differentiated depending on (3) the injured structures: IIa ligamento-osseous, type IIb purely ligamentous (rarest with 0.6%). According to our classification, the CCI severity increases from type Ia to IIb. CCI are more important than previously believed and seen as an indication for surgery. The exclusion of further, contra-polar injuries in the event of a clavicle injury is clinically relevant and should be focused.

Surgical Versus Nonsurgical Treatment of Lateral Clavicle Fractures: A Short-Term Follow-Up of Treatment and Complications in 122 Patients

OBJECTIVES

To assess the total number of procedures in initially surgically and nonsurgically treated patients with lateral clavicle fractures and to compare patient-reported outcome measures (PROMs).

DESIGN

Retrospective cohort study.

SETTING

Level 1 trauma center.

PATIENTS

One hundred twenty-two patients with lateral clavicle fractures treated at Uppsala University Hospital from 2013 to 2015 were included in a patient record review. A subgroup of 30 patients was assessed at a study follow-up visit at a median of 3 years postinjury.

INTERVENTION

Comparisons between initially surgically and nonsurgically treated patients.

MAIN OUTCOME MEASUREMENTS

Rates of surgical treatment, reoperations, and delayed surgeries. PROM subgroup: Constant score; Disabilities of the Arm, Shoulder and Hand score; and Visual Analog Scale over satisfaction with the cosmetic results and interview-based information on subjective complaints and reflections.

RESULTS

Of 23 surgically treated patients (22 Neer type II and V fractures), 10 underwent subsequent implant removal, after which 1 developed symptomatic nonunion. Of 99 nonsurgically treated patients (36 Neer type II and V fractures), 2 underwent delayed surgery because of symptomatic nonunion. In the PROM subgroup, the surgically treated patients had worse Constant scores, complained of infraclavicular sensory deficits, and were less satisfied with the cosmetic result than the nonsurgically treated patients.

CONCLUSIONS

Half of the surgically treated patients underwent implant removal, whereas delayed surgeries in nonsurgically treated patients were very rare. Nonsurgical treatment should be considered more often as an alternative to surgery even for the usually surgically treated Neer type II and V lateral clavicle fractures.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Management of Distal Clavicle Fractures - A Survey of UK Shoulder and Elbow Surgeons

Background

Distal clavicle fractures (DCF) are a management challenge frequently encountered by shoulder surgeons. Despite an array of surgical fixation strategies, the indications and role of surgery are unclear, with there being no gold standard or consensus regarding their management. The aim of this study was to identify current United Kingdom (UK) clinical practices relating to DCFs and to inform a future randomised control trial (RCT).

Methods

An online survey was sent to the consultant surgeon members of the British Elbow and Shoulder Society (BESS). Questions covered respondent indications for surgical fixation, important factors considered for management of DCFs, fixation strategies, the volume of patients treated, and willingness to participate in the conduct of a randomized trial.

Results

The response rate was 84/327 (26%). 64-67% of respondents reported surgically managing DCFs classified as Neer type 2A, 2B and 5. The most important factors considered by surgeons when deciding between operative and nonoperative intervention were degree of displacement (90%), clinical assessment of impending open fracture (87%), and age of the patient (74%). For conservatively managed DCFs, the preferred length of complete immobilization was 2-4 weeks (46%), followed by 4-8 weeks (17%). 30% reported not immobilizing their patients at all. For operative intervention, the locking plate was the preferred fixation method by most respondents (68%), although there was no clear consensus regarding other fixation methods. Most surgeons (52%) reported treating a low volume of patients with DCFs (0-10) per year. 58% of respondents were willing to randomize patients to non-operative treatment in a multi-centre RCT, with a further 22% undecided. Finally, 68% (n=79) of respondents would consider being co-investigators in such a trial.

Conclusion

There is considerable heterogeneity in the management of patients with DCFs in the UK. The indications for surgery and the optimal surgical fixation method remain uncertain. There is a clear need for pragmatic multi-centre clinical research in this area.